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Medical information that require documentation in medical records

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Now to go on along the path from my previous post on Standards with requirements that require documentation in a medical record (this link opens in a new tab of your current window), this post is all about aspects of JCI’s standards and requirements that directly affect medical information which requires documentation in medical records.

From all my previous posts on medical information, and a close check on the 4th Edition of Joint Commission International Accreditation Standards For Hospitals, shows that the following medical information requires documentation in a medical record :

  1. Initial medical assessments and Initial nursing assessments, both of which are documented in the patient’s record and readily available to those responsible for the patient’s care; these initial assessment(s) results in an initial diagnosis
        1. An initial diagnosis is a very important notation of a doctor’s assessment and his or her learned conclusion to a definite initial diagnosis. So it is undoubtedly a part of medical documentation, and is thus a part of the assessment documentation.
        2. Standard AOP.1.2 has no direct reference to documentation by the doctor and the nurse, obviously the doctor and the nurse will record all their initial assessments in the medical records.
        3. Thus, I have counted this standard as an explicit standard for medical information documentation and as one of the several requirements (more on this after I have concluded posts on surgical information) for what information must be recorded in the medical record by the hospital’s various health care providers.
  2. Pain assessments for all inpatients and outpatients who are screened for pain and assessed when pain is present and recorded in a way that facilitates regular reassessment and follow-up
  3. All Patient Orders, including medication, diagnostic imaging and clinical laboratory test orders are written in the medical record
  4. Care Plans and Team meeting discussions, when the staff responsible for the patient work together to analyse the assessment findings and combine this information into a comprehensive picture of the patient’s condition; from this collaboration, the patient’s needs are identified, the order of their importance is established, and care decisions are made – integration of finding at this point facilitates the coordination of care provision; the results or conclusions of any patient care team meetings or other collaborative discussions are written in the patient’s record
  5. A discharge summary which contains follow-up instructions for the patient’s continuing or follow-up care, prepared at discharge by a qualified individual of which a copy is placed in the patient’s medical record

From the list above of medical information that require documentation in a medical record, I have a count of seven (7) standards which explicitly state what is to be documented in a medical record with a total of ten (10) requirements which includes explicit and implicit instances that require documentation in a medical record.

The charts below (a larger view of each chart is displayed in a new tab of your current window, by clicking on each chart) show these 7 standards with the 10 requirements.

I believe, a Health Information Management (HIM) / Medical Records (MR) practitioner working in a hospital must be aware and knowledgeable that the quality of his or her medical records, in his or her custody and care is determined by their contents. The medical records must contain all of the medical information as I spoken of above, recorded in them. This condition is regardless of the type of hospital they work at, irrespective if his or her hospital had acquired JCI accreditation status or one that is seeking JCI accreditation status or it is one that is not seeking JCI accreditation status at all.

References :
Joint Commission International 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA

Plan Of Care

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Problems are identified from the initial medical and nursing assessments for each patient, and a plan of care (POC) is implemented soon after by the responsible physician, nurse, and other health professionals with the involvement of the patient and family to address these problems using the data from the initial assessments.

Image credit : todaysseniorsnetwork.com

The POC is a written guide that organises data about a patient’s care into a formal statement that will be used to help the patient achieve optimal health. Therefore, a carefully formulated written plan of care is developed within 24 hours of admission as an inpatient in order to provide quality patient care by prioritising problems and addressing short- and long-term needs of the patient by prioritising treatments, setting realistic goals and developing expected outcomes (outcome identification), planning medical and nursing interventions (with collaboration and consultation between care providers as needed) to meet the patient’s needs, and finally documenting the care plan.

Systematic monitoring and observation performed by the patient’s health care practitioners related to specific problems during ongoing assessments (reassessment) allow to determine the patient’s response to medical and nursing interventions and to identify any emerging problems so as to update the plan as appropriate or to confirm the validity of the data obtained during the initial assessments, thus allowing in compiling a comprehensive database of the patient’s health to achieve the desired outcomes.

Reassessment detect the patient’s changing needs as the result of clinical improvement or new information from a routine reassessment (for example, abnormal laboratory or radiography results), or they may be evident from a sudden change in the patient’s condition (for example, loss of consciousness). The plan for the patient’s care also changes.

The Joint Commission International (JCI) Standard COP.2.1 requires the documentation of a single, integrated care plan that identifies measurable progress (goals) expected by each discipline as opposed to the entry of a separate care plan by each practitioner. This individualised plan of care related to his or her identified needs must be evident for each patient in the patient’s medical record.

During the accreditation survey, the reviewer looks for evidence of an organised and systematic method of monitoring and evaluating patient care that is reflected through changes in the documentation of the medical record as notes to the initial plan or as revised or new care goals, or in a new plan.

The Health Information Management (HIM) / Medical Records (MR) practitioner working in a hospital with JCI accreditation status or one that is seeking accreditation status must ensure that all medical records are complete with a  POC.

Medical records will be used to proof evidence of POC for each patient to fully meet the seven (7) requirements for this standard which ensures compliance with JCI’s plan of care requirements as follows :

  1. The care for each patient is planned by the responsible physician, nurse, and other health professionals within 24 hours of admission as an inpatient
  2. The planned care is individualised and based on the patient’s initial assessment data
  3. The planned care is documented in the record in the form of measurable progress (goals)
  4. The anticipated progress (goals) is updated or revised, as appropriate, based on the reassessment of the patient by the interdisciplinary health care practitioners
  5. The care planned for each patient is reviewed and verified by the responsible physician with a notation in the progress notes
  6. The planned care was provided
  7. The care provided for each patient is written in the patient’s record by the health professional providing the care

Since Standard COP.2.1 clearly states the POC provided to each patient is planned and written in the patient’s record by the health professionals providing the care, justifies this standard to be included as medical information.

References :
Caroline, BR & Mary, TK 2012, Textbook of basic nursing, 10th edn, Wolters Kluwer Health, Lippincott Williams & Wilkins, Philadelphia, USA

Joint Commission International 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA

Sue, CD & Patricia, KL 2011, Fundamentals of Nursing: Standards & Practice, 4th edn, Delmar, Cengage Learning, NY, USA

Standards with requirements that require documentation in a medical record

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The rush for Joint Commission International (JCI) accreditation and certification has spread across Asia – from Turkey and Jordan to China and Singapore, and of course to Malaysia too.

In the wake of this rush by many hospitals which are on their way to acquire what is known as a “Gold seal of Quality”, an international accreditation award given to healthcare establishments internationally if they meet or exceed JCI standards by JCI based in the United States, I think it is imperative that Health Information Management (HIM) / Medical Records (MR) practitioners working in such hospitals must examine how JCI accreditation and certification affects them and what they must do to thrive under it.

In this post and in subsequent posts, read about the aspects of JCI accreditation and certification that directly affect medical information and surgical information that require documentation in medical records, and to learn about the role of care providers play for what portions of both medical and surgical information that must be recorded in the medical record (what they say) from what they do to improve quality of patient care and reduce costs in this quality system of accreditation and certification.

Allow me to lead you along the path of another new post after this one, to aspects of  this quality system of accreditation and certification from JCI that directly affect medical information that require documentation in medical records.

But before that, some rules to identify the standards and the requirements found in the Joint Commission International Accreditation Standards For Hospitals 4th Edition relevant to medical information and surgical information, that require documentation in a medical record which form the greater part of what is called “the contents of a medical record”.

Familiarity with the Joint Commission International Accreditation Standards For Hospitals 4th Edition indicates that JCI has standards which explicitly state what is to be documented in a medical record and also has standards which implicitly hints what is to be documented in a medical record.

Standards which explicitly state in the standard statement and / or  in a corresponding Measurable Elements (ME) of each standard what is to be documented in a medical record contain statement(s) and /or phrases like :

  • Standard AOP.1.3 statement which states “The patient’s medical and nursing needs are identified from the initial assessments and recorded in the clinical record.”
  • Standard ASC.5.2 statement which states “The anesthesia used and anesthetic technique are written in the patient record.”
  • “documented in the patient’s clinical record”
  • “entered into the patient’s clinical record”
  • “recorded in the patient’s record”
  • “written in the patient’s record”

For example, Standard AOP.1.3 states “The patient’s medical and nursing needs are identified from the initial assessments and recorded in the clinical record.”, and has two MEs that explicitly state what is to be documented in a medical record, namely ME3 and ME 4 which state “The identified medical needs of the patient are documented in the patient’s clinical record.” and “The identified nursing needs of the patient are documented in the patient’s clinical record.”, respectively.

Standards which implicitly hint to what is to be documented in a medical record have words or phrases or complete statements which hint of documentation of what is to be included in a medical record like :

  • “The clinical records of inpatients contain a copy of the discharge summary.”, which is the Standard ACC.3.2 statement
  • “The initial assessment(s) results in an initial diagnosis” which is the ME 4 for the Standard AOP.1; an initial diagnosis is obviously a medical information by a doctor
  • “Patient records contain a list of current medications taken prior to admission, and this information is made available to the pharmacy and the patient’s health care practitioners.” which is the ME 5 for the Standard MMU.4

For example, the Standard ACC.3.2 states “The clinical records of inpatients contain a copy of the discharge summary.” and its corresponding ME 3 states “A copy of the discharge summary is placed in the patient record.”

Standards which explicitly state what is to be documented in a medical record and standards which implicitly hint what is to be documented in a medical record, make up the “requirements”  to form the greater part of the contents of a medical record. To make it clearer, I mean to say “requirements” refers to what goes into a medical record.

Image credit : http://www.ppt-learning.com/

I guess I have made the rules clear for an understanding of my next post on medical information that warrants documentation in a medical record.

References :
Joint Commission International 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA

Postings about medical documentation

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When I wrote “With this post, I believe I have covered postings about medical documentation found in a typical medical record and their relationship to the relevant JCI standards.” at the end of the post Collaboration, and the holistic care of the patient (this link will open in a new tab of your current window), I inadvertently missed out posting about the Standard COP.2.2 of the Joint Commission International (JCI) which is about “Those permitted to write patient orders write the order in the patient record in a uniform location”. and also about the Standard COP.2 which states “There is a process to integrate and to coordinate the care provided to each patient”. Actually the Standard COP.2 is linked with the standards I discussed under Collaboration, and the holistic care of the patient (this link will open in a new tab of your current window), i.e Standard AOP.4 and Standard AOP.4.1. I discussed Standard COP.2 under the post Process to integrate and to coordinate the care provided to each patient (this link will open in a new tab of your current window),

Since written patient orders as well as the results or conclusions of any patient care team meetings or other collaborative discussions written in the patient’s record are both medical documentation, I rushed to post about Standard COP.2 and Standard COP.2.2 in the post Process to integrate and to coordinate the care provided to each patient (this link will open in a new tab of your current window) and in the post Written patient orders (this link will open in a new tab of your current window)., respectively.

I think I can safely say now I have finally covered postings about medical documentation found in a typical medical record and their relationship to the relevant JCI standards.

Process to integrate and to coordinate the care provided to each patient

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The previous post Collaboration, and the holistic care of the patient (this link will open in a new tab of your current window), discussed collaboration between members of an interdisciplinary health care team in a hospital comprising of medical, nursing, and other individuals and services responsible for patient care when they use an interdisciplinary approach to analyse and to integrate patient assessments through which they identify the most urgent or important care needs for the patient.

Any results or conclusions from collaborative patient care team meetings or similar patient discussions reflecting this integration and coordination of care are written into the patient’s medical record showing each practitioner’s own observations and treatments.

If there is documentation in the medical record of patients as evidence of a process to integrate and to coordinate the care provided to each patient in the hospital, then this evidence meets the  Joint Commission International (JCI) requirement for the Standard COP.2 which states “There is a process to integrate and to coordinate the care provided to each patient”.

Integrating and coordinating care planning and care delivery among settings, departments, and services meets the JCI Standard COP.2 and the requirements ME1 and ME2. Documenting the results or conclusions of any patient care team meetings or other collaborative discussions in the patient’s medical record in turn meets the JCI Standard COP.2 requirement ME 3.

A Health Information Management (HIM) / Medical Records (MR) practitioner working in a hospital with JCI accreditation status or one that is seeking accreditation status, must know how the patient’s medical record facilitates and reflects the integration and coordination of care when each practitioner records observations and treatments in the patient’s medical record. Also, when any results or conclusions from collaborative patient care team meetings or similar patient discussions are written in the patient’s medical record.

References :
Joint Commission International 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA